Child Care Assistance Application

Laurie Gill

Interim Secretary

CHILD CARE ASSISTANCE APPLICATION
FOSTER CARE

Application Instructions

Read the application carefully and answer each question completely. If you have any questions about completing this application, you can call (605) 773-4766, toll-free 1-800-227-3020, or email CCS@state.sd.us.

If your provider is not registered or licensed, they must be pre-approved by Child Protection Services before we can issue any payments to that provider. Contact your child’s social worker prior to making arrangements for non-regulated care.

If you need to locate a registered or licensed child care provider, click here.

Child care providers will bill directly to Child Care Services for reimbursement. If your provider charges more than Child Care can pay, please contact your Child Protection Social Worker for additional options.

First Name:

Middle:

Last Name:

Mailing Address:

City:

State:

Zip Code:

County:

Address where you live (if different than mailing):

City:

State:

Zip Code:

County:

Home Phone Number: - -

Work Phone Number: - -

CPS Social Worker's Name:

Phone Number: - -

CHILD INFORMATION

Complete for each foster child in your care.

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Foster Child Name (Last, First, Initial)	Race (optional) Check all that apply	Hispanic or Latino?	Sex	Date of Birth	Social Security Number (optional)	Date Child Placed in Care
	White/Caucasian Native American/Alaska Native Black/African American Native Hawiian/Pacific Islander Asian/Oriental	YesNo			- -

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawiian/Pacific Islander
Asian/Oriental

YesNo

- -

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawiian/Pacific Islander
Asian/Oriental

YesNo

- -

Enter another child

EDUCATION or TRAINING

Do you need help paying for child care in order to go to school? YesNo

You must include an offical school schedule for each adult family member attending school

Student's Name	Place of Education or Training	Credit Hours	Starting Date	Ending Date	Contact Person	Phone Number
						- -

Enter another student

EMPLOYMENT

Do you need help paying for child care in order to work? YesNo

Complete the following section for each place of employment for every adult in the household.

Place of Work:

Date Employment Began:

Phone: - -

What times do you work? (example 8 am - 5 pm)

Total weekly hours worked:

Enter another job

FEDERAL REGULATIONS GOVERNING THE USE OF CHILD CARE FUNDS REQUIRE A RESPONSE TO THE FOLLOWING QUESTIONS:

Is any household member active duty in the U.S. Military? YesNo

If yes, please indicate who:

Is any household member in the National Guard or Military Reserve? YesNo

If yes, please indicate who:

What is the primary language spoken in your home?

Do your family assets exceed $1,000,000? YesNo

CHILD CARE NEED

Fill out the following information for each child in child care.

Child's Name:

Is this child in school? YesNo

If yes, what hours? (example 8:00-3:15):

Is the child in a pre-school program run through the school district or a Head Start program? YesNo

If yes, please list the name of the program:

Contact Person:

Enter another child

CHILD CARE PROVIDER

If your provider is an in-home or informal provider, he/she must be pre-approved by Child Protection Services before we can process your application. Contact your child’s social worker prior to making arrangements for in-home or informal provider care.

If you have more than one child care provider, please fill out the following information for each of them.

Provider Name:

Provider Phone: - -

Provider Address:

City:

Provider ID Number:

Cost of care per child (include if hourly, weekly, etc.):

Type of provider: ?

Does this provider care for all your children? YesNo

(if no, list those cared for):

What days and hours does this provider care for your children?

When did the provider begin caring for your children?

Enter another child care provider

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